Home diagnostic devices such as the Tyto and MedWand let patients do tests at home, send the information to a doctor

Telemedicine offers patients the chance to meet with a doctor, 24/7, without leaving home. But many physicians are wary of participating because they can’t peer into patients’ ears, look down their throats or listen to their lungs remotely.

A new genre of home diagnostic devices aims to address those concerns by giving patients some of the same tools that doctors use during in-office exams. Think part Star Trek Tricorder, part Harry Potter Extendable Ear.

The closest to market is Tyto, a hand-held gizmo about the size of a softball. One attachment works like a stethoscope to capture and record a patient’s heartbeat and breath sounds. Other attachments allow a built-in camera to get a good look at patient’s tonsils and into the ear canal. The camera can also take high-resolution photos of skin lesions, rashes and moles. All the images, sounds and readouts can be shared with a doctor over the internet in real time or stored in a software program for later use.

“We are replicating the face-to-face primary care visit, just doing it remotely,” says Dedi Gilad, who founded the Israel-based company Tyto Care Ltd. after making frequent trips to the pediatrician when his daughter was in kindergarten in 2012.

Set for launch

Tyto is awaiting clearance from the Food and Drug Administration. The company expects to introduce the device in the U.S. and Israel later this year, offering it first through health systems and insurers. Roy Schoenberg, chief executive officer of American Well, which creates the telemedicine platforms offered by many large health systems, says any provider using its systems will be able to connect with Tyto. The device will be available directly to consumers sometime next year, for about $299, Tyto Care says.

MedWand, another remote diagnostic tool, looks like a fat electric toothbrush and performs many of the same functions as Tyto, but also checks blood pressure, blood glucose and blood oxygen levels and lets doctors conduct eye exams remotely. Its creator, M. Samir Qamar, is the CEO of MedLion, a network of direct primary-care practices in 25 states. Those practices charge patients a flat monthly fee and deliver much of their care via telemedicine, but Dr. Qamar says he found it was stuck in the “video-chat stage.” MedWand, which will sell for $250, will allow doctors to provide more and better care remotely, he says.

Like the Tyto, MedWand will also be available first through telemedicine companies and health-care systems. “It’s just a paperweight unless there’s a bona fide, high-quality medical service provider on the other end,” Dr. Qamar says.

Still another device, called the Scanadu Scout, can measure temperature, heart rate, blood pressure and blood oxygen level when held to the user’s forehead. The manufacturer, Scanadu of Sunnyvale, Calif., is testing it with about 7,000 consumers world-wide, but has yet to receive FDA clearance.

The missing link

Consumers have been able to buy stethoscopes, otoscopes and other medical devices for decades, but using them correctly and getting the information to doctors can be difficult.

Telemedicine proponents say the new wave of home diagnostic devices could well provide the “missing link” in telemedicine, reassuring both doctors and patients that a virtual visit can still be thorough. While some 70% of large U.S. employers offer telemedicine visits as a benefit this year, only about 3% of eligible employees have taken advantage of them so far, according to a new survey by the National Business Group on Health.

“Devices like Tyto are going to dramatically increase the value of telehealth and the type of service that can be delivered over these channels,” American Well’s Dr. Schoenberg says.

Demonstrating that they provide accurate information will be critical to acceptance, some doctors say. “When you’re looking at a rash or listening to the lungs, the quality of the images and sounds is very important,” says Wanda Filer, a family physician in York, Pa., and board chairwoman of the American Academy of Family Physicians. More family physicians are using telemedicine, which the academy supports, she says, “as long as it’s in the context of a continuing doctor-patient relationship.”

To be sure, clinicians still can’t draw blood or swab a throat for strep remotely—but other home tests are coming.

Scanadu is also developing disposable urine-analysis tests, much like home pregnancy tests, to let consumers test for urinary-tract infections, excess protein and other medical problems. A smartphone app analyzes color changes on the test paddles and can report the results on the spot.

“We are getting a lot of attention from telemedicine companies,” says Alexander Cristoff, the company’s vice president of marketing.

Beginning Thursday, Sept. 22, the Anchorage hospital will virtually beam critical care doctors 800 miles away to the emergency room of the clinic to assist staffers there during medical emergencies, thanks to a satellite link instead of the usual fiber optics. – Rachel D’Oro

Doctors in Anchorage will now be able to join a teleconference in the emergency room on Unalaska Island, 800 miles away.

The only clinic in one of the nation’s busiest commercial fishing ports is so remote that even conventional telemedicine for emergencies has been impossible for its limited staff—until this week.

Starting Thursday, a new partnership with an Anchorage hospital will virtually beam critical care doctors 800 miles away to the emergency room on Unalaska Island, home to Dutch Harbor.

But instead of transmissions with fiber-optics, which are nowhere near the isolated Alaska island, the team putting together the system is relying on satellite technology in what is believed to be a first in the country for telemedicine.

The clinic, Iliuliuk Family and Health Services, brings to nine the number of providers served by the electronic intensive care unit at Anchorage’s Providence Alaska Medical Center.

“We are kind of mix-mashing everything together to try to make this work,” Sharon Compton, services manager of the hospital’s eICU office, said after a recent demonstration of the Dutch Harbor link.

The new system will provide real-time camera links between emergency doctors and clinic staffers during medical emergencies, such as injuries among the Bering Sea crabbing fleet made famous by the Discovery Channel show “Deadliest Catch.”

The idea is to help stabilize patients before transporting them out of town and to help with triage during major events like a ship sinking.

From afar, doctors will be able to view X-rays and patient charts and talk directly with patients on camera instead of consulting with medics by phone and email.

There are some unknowns about how the system will work, with likely slowdowns in satellite reception because of the region’s notoriously bad weather.

During the recent demonstration, pre-launch kinks prevented the rolling-cart-mounted camera in Dutch Harbor from being pivoted remotely. But the camera otherwise performed impressively, sending back crystal-clear video of clinic staffers as they chatted with a critical care doctor.

The new service was lauded by Seattle-based crabbing boat owner by Lance Farr, who has been badly hurt twice in his decades of working in the Bering Sea.

Several years ago, he almost severed a finger in a dockside engine accident. He was stabilized at the clinic before being flown to Anchorage for further treatment. In 1996, Farr broke his foot at Dutch Harbor after dropping an engine on it. He spent the night at the clinic under the care of nurses before being flown out the next day.

In hindsight, having his care visually monitored by emergency room specialists would have provided a morale boost, as well as invaluable expertise, Farr said.

“It would be a good thing, I would think, to have a real physician being able to advise the people out there,” he said.

The city of Unalaska has just 4,600 year-round residents, but the population swells to 16,000 or more during the region’s two main fishing seasons, when boat crews and processing workers flood the town with dozens of languages and cultures. That means more potential for patients, including people who don’t speak English.

The clinic averages more than 300 after-hours emergency room visits a year, with about a third of those patients flown elsewhere, often to Anchorage, for more complete treatment.

Fishing-industry emergencies at sea can mean significant delays to appropriate medical treatments when the injured must first be carried by rescue helicopter to Dutch Harbor. Injuries can range from deep cuts and broken bones to back injuries and amputations.

“These guys are pretty tough out here, and they will, you know, continue to fish until they can’t get out of bed anymore,” said James Novotny, nurse practitioner at the clinic.

The drastically shifting population can put a strain on clinic staffing in this rural setting. So can the inability to afford emergency specialists or much in the way of diagnostic equipment.

Then there’s the challenge of living in such a far-flung spot, which makes finding and keeping medical staff difficult, according to clinic medical director, Ann Nora Ehret, an osteopathic doctor who has wanted to tap into telemedicine since joining the staff in 2013. Only recently did the clinic hire a second doctor after the position was vacant for nearly a year.

Adding the long-distance help will be invaluable, Ehret said.

“I think it could be a game changer for recruiting, retention and for the care of the patients,” she said. “We are getting the support we need in an austere environment.”

Arkansans will now be able to use telemed the way every other state (except Texas) does. The state’s Board of Medicine approved regulations that allow a doctor and patient to establish a relationship via telemedicine.

The medical board’s approved regulations outline a “proper physician-patient relationship” to include “a face-to-face examination using real time audio and visual telemed technology that provides information at least equal to such information as would have been obtained by an in-person examination.”

As the American Telemedicine Association reports, the board also assumes the licensing regulatory responsibilities for other allied health professionals, including occupational therapists, respiratory therapists, physician assistants and radiologists assistants, but it isn’t known now whether the medical board will pursue additional regulation for the use of telehealth for these professionals.

For the last few months, telemedicine efforts have been stalled in Arkansas (which ranks last in the nation in telemedicine practice standards according to the American Telemedicine Association). In July, a rule that would have made remote visits more permissible was stalled when a key legislative panel declined to sing off. The contention was over language around store and forward technology, which had been approved by the state’s Medical Board but then changed after the public comment period had ended, which lawyers said required a new public comment period.

A month later, the medical board moved forward on one rule to promote telemedicine by allowing the use of audiovisual technology to establish a doctor-patient relationship. But the medical board still rejected another that would change the requirements that allow non-video companies like Teladoc to see patients in the state.

The board will meet October 6 to discuss another set of regulationsthat establish telemedicine standards of care.

About Physician Licensing Service

Now in our 20th year of business, Physician Licensing Service has been changing the face of healthcare licensure. We have developed a proven system to remove the barriers common to state medical licenses and get doctors practicing in record time. Our business model focuses on simplifying the process for all involved parties. This includes the state medical boards themselves, because PLS takes great care to keep abreast of their updates in this ever changing field, and work within those guidelines. For a doctor seeking a medical license, PLS will take on the entire process, including eligibility research, paperwork, verifications, and follow up.

Practicing Medicine Across State Lines: 5 Things You Should Know About the Medical License Debate

Written by Laura Dyrda | December 14, 2015

Should medical licenses become more like drivers’ licenses? There are some who think so according to a report in The Bulletin.

State currently have different medical licensing standards and it’s a time-consuming process to obtain a medical license in multiple states. Yet with the interconnectivity growing in the United States, and mobility more prevalent, there are some physicians advocating for more standard requirements allowing physicians to treat patients across the United States.

Here are five key thoughts on trends in medical licenses:

To continue reading the original and remaining article, please visit Becker’s ACS Review by clicking here:

About Physician Licensing Service

Now in our 19th year of business, Physician Licensing Service has been changing the face of healthcare licensure. We have developed a proven system to remove the barriers common to state medical licenses and get doctors practicing in record time. Our business model focuses on simplifying the process for all involved parties. This includes the state medical boards themselves, because PLS takes great care to keep abreast of their updates in this ever changing field, and work within those guidelines. For a doctor seeking a medical license, PLS will take on the entire process, including eligibility research, paperwork, verifications, and follow up.

When it comes to telemedicine, navigating the reimbursement process can be tricky. What rules do you need to follow to ensure you get paid? How do you know your patients are eligible for telemedicine? How does the billing process actually work?

We get these questions all the time at eVisit. While the answers vary a bit depending on which payer you’re talking about, it’s usually easiest to start with Medicare.
Medicare currently provides coverage for more than 55 million older Americans. Doing telemedicine with your Medicare patients is a huge opportunity to make a difference in their care experience, especially since Medicare patients are the most likely to have multiple chronic health issues and need frequent care.

So how does telemedicine reimbursement through Medicare work? The good news is, since Medicare is a national program, the guidelines for telemedicine are the same no matter what state you’re in. That makes things a little easier than navigating reimbursement through Medicaid or private payers.

Here are answers to the top questions we hear about Medicare and telemedicine reimbursement.

Does Medicare reimburse for telemedicine?

Yes! Medicare has covered telemedicine for many years now in order to increase care access to Medicare patients.

What types of telemedicine does Medicare cover?

There are several different kinds of telemedicine, including real-time, store-and-forward, and home monitoring. Currently, Medicare covers real-time, live video telemedicine in all 50 states. Store and forward telemedicine (which involves sharing patient medical data remotely for diagnosis and analysis, and does not require the patient to be present) is actually also covered by Medicare, but not billed as a telemedicine service. CMS advises physicians to bill these services the same way as medical services delivered onsite.

As of 2015, Medicare also now provides some coverage for home monitoring under the new chronic care management CPT code 99490.

Store-and-forward telemedicine services are only covered in Alaska and Hawaii, and home monitoring is not covered at all.

Keep in mind that if you’re a provider not included on this list, you may still be able to practice telemedicine depending on your state medical board recommendations. But under Medicare, you would not be able to bill and get paid for that service.

What is an originating site? And what’s a distant site?

If you’ve been reading up on Medicare and telemedicine at all, you probably noticed the terms “originating site” and “distant site.” Understanding these is very important. The originating site means the location where the Medicare patient is at the time of the telemedicine service. The distant site means where the healthcare provider is at the time of the telemedicine service.

While many of us now think of telemedicine as a secure video conference between a patient at home and a healthcare provider at their office (or home), Medicare hasn’t yet caught up to this idea. Traditional Medicare does not yet recognize the patient’s home as an eligible originating site.

Traditionally, patients participating in telemedicine would come to a local health center to see their primary care doctor, and that doctor would use a telemedicine system to include a distant specialist in the appointment. Now that telemedicine has expanded well beyond this model, the Medicare rules need some updating.

So, what qualifies as an eligible originating site?

To qualify as an eligible originating site, the location has to meet two conditions:

It has to be located in a Health Professional Shortage Area (HPSA) or a county outside of a Metropolitan Statistical Area (MSA). Check whether an address is in a HPSA with this quick tool.

You can find a complete list of the covered CPT and HCPCS codes on this handout from Medicare. See pages 3 and 4.

How do I bill telemedicine?

As long as you’ve met all the other Medicare guidelines for telemedicine (eligible provider, distant site, originating site), billing is as easy as choosing the appropriate covered CPT code and adding the modifier “GT.” The GT modifier tells Medicare that the service was delivered via telemedicine.

How much will I get paid?

You’ll get paid the same amount for a telemedicine service as the corresponding in-person service. Just look-up the CPT code on the Medicare physician fee schedule to see the amount.

When will the restrictions on eligible originating site change?

While there’s nothing definite yet, legislators proposed the Medicare Telehealth Parity Act of 2015 this past July that would eliminate some of the restrictions on eligible originating sites. The bill would also expand the eligible healthcare providers and medical services. You can stay tuned on policy updates by following us (@eVisit) and the Southwest Telehealth Resource Center (@UA_ATP)!

Does telemedicine reimbursement work differently for traditional Medicare and Medicare Advantage plans?

Yes! All the restrictions and guidelines outlined here apply to traditional Medicare. In contrast, Medicare Advantage plans fall under private payers and have flexibility to cover telemedicine reimbursement as they wish.

In other words, if one of your patients has a Medicare Advantage plan, getting reimbursed for telemedicine will likely be much easier!

About Physician Licensing Service
Now in our 18th year of business, Physician Licensing Service has been changing the face of healthcare licensure. We have developed a proven system to remove the barriers common to state medical licenses and get doctors practicing in record time. Our business model focuses on simplifying the process for all involved parties. This includes the state medical boards themselves, because PLS takes great care to keep abreast of their updates in this ever changing field, and work within those guidelines. For a doctor seeking a medical license, PLS will take on the entire process, including eligibility research, paperwork, verifications, and follow up.

Rumors of USMLE Time Limit Eliminations are Unfounded

The following summary was pulled directly from the UMSLE website this week:

State Board Sponsorship For Step 3 To Be Discontinued In 2014

With the introduction of the restructured Step 3 examination in 2014, the USMLE program will no longer require examinees to apply for Step 3 under the eligibility requirements of a specific medical licensing authority.

All other Step 3 eligibility requirements (i.e., medical degree, passing Steps 1-2, ECFMG certification for IMGs) will remain applicable, as will all other USMLE program requirements (e.g., no more than 6 attempts at a Step or a Step component).

This change in the application process is tentatively scheduled to begin in August 2014.

Note: Removing state board sponsorship as part of the Step 3 examination application does not impact medical licensing requirements in the United States. Most medical licensing authorities have, and will continue to maintain, specific criteria for completion of the USMLE, such as time and attempt limits.

At this time, there are no plans for the USMLE program to impose a minimum residency training requirement as part of the Step 3 eligibility criteria. However, the USMLE program will likely continue to recommend that individuals take Step 3 at or near the completion of the first year of residency training.

Courtesy of USMLE announcement portal

This announcement confirms that physicians who are outside timeframe and/or attempt limits for a particular state will still not qualifyfor that state license after the August 2014 changes for state sponsorship go into effect.

This is a good opportunity to address trainees who are preparing to take USMLE exams:

Do not take these examinations lightly- Just because you can take the exams again, does not mean that you should. Your ability to practice in the state of your choice in the future isdetermined by your scores, attempts per step and the time frame in which you completed all three steps. If you do not meet the requirements for a particular state, you will not be able to get a license to practice in that state. Even if you have an offer of employment, even if it’s your home state, even if your spouse has been offered the job of a lifetime in that state- You will not be working as a physician in that state if you do not meet the USMLE requirements for that state.

If you have questions about the USMLE requirements for each state, please click here. If you have questions about possible waivers, please call us at 888-551-2140.

Top 10 Challenges Facing Physicians in 2014

From: Medical Economics

Every challenge is an opportunity.

While this list of 10 challenges facing physicians seems daunting and nearly insurmountable for smaller office-based practices, many believe there is tremendous upside for primary care physicians in leading healthcare delivery in the United States in 2014 and beyond. The result could mean more autonomy; it could mean better quality of life for you and your patients, and hopefully result in less interference with the doctor-patient relationship. But it’s going to take work, management experts say. Physicians will need to reinvent their operations to create efficiencies and thoroughly evaluate the revenue cycle to maximize cash flow. That means you will need to review payer contracts, and look at adopting technology to improve patient care. You may have to re-engineer workloads, workflows and staff responsibilities. It is this premise that Medical Economics is showcasing with this list of 10 challenges and opportunities facing physicians next year. We believe that understanding the dynamics of a changing market will ultimately help physicians shape it, adapt to it and succeed. Over the course of this past year, we have learned through interviews and surveys that you find tremendous professional satisfaction from helping patients improve their lives. In fact, it continues to be the reason you entered medicine, and the reason you will stay. At the same time there are trends outside of this relationship that are interfering with your time with patients and continually threatening the economic viability of your practice. Healthcare is in the throes of great change. And history has shown that large-scale disruption incubates innovation. Our collective opportunity as a healthcare profession is to build a stronger healthcare delivery system rightfully led by primary care that seeks to remain cost conscious, efficient in its delivery, and fairly compensated for helping people attain the most precious commodity of all—a healthy life. —Daniel R. Verdon

Challenge #1: Payment for medical services

ACA and changing payment trends Healthcare’s ailing reimbursement system will likely take a turn for the worse in 2014, before it recovers.

And while 2013’s payment structure seems dehydrated to many physicians because of tighter negotiated payments by health insurers, escalating costs of doing business, and the seemingly endless cascade of bureaucracy tied to payments, some believe relief won’t be felt for the cadre of U.S. physicians in office-based practices for some time.

Why? Healthcare is in the midst of transformational change in the way it is financed. Fifteen of the 16 key provisions of the Affordable Care Act (ACA) will take effect in 2014, and they will most definitely impact the numbers of patients you see and the way you are paid for medical services.

Despite the flawed rollout of the insurance exchanges this fall, coverage for new health insurance enrollees begins on January 1. The new law stipulates that insurance companies cannot drop coverage based on pre-existing conditions. For states that have opted to expand Medicaid, that coverage also begins in January.

While more people are reportedly enrolling in the exchanges, U.S. residents will be required to have qualifying health coverage or face financial penalties. Wellness programs allow employers to offer employees rewards of up to 30%, potentially increasing to 50%, of the cost of coverage for participating in a wellness program and meeting certain health-related standards. The ACA also creates a 10-state pilot program (by July 1, 2014) to track and monitor successes.

On March 31, the insurance exchanges close for 2014 enrollment, and we will have a barometer to gauge how many newly insured Americans entered the market. Data related to physician payments for services by health insurers will also offer another indicator. Here are some of the keys to watch for next year.

The narrow networks squeeze

Payers are consolidating networks and repositioning in markets as a result of the ACA. We saw the results play out from October through December as physicians received termination notices from key health insurers in more than 10 states regarding network consolidation for Medicare Advantage. These moves have impacted thousands of physicians and patients, and this trend may not go away anytime soon.

Narrow networks are believed to offer payers more bargaining power in negotiating contracts with providers and lowering costs of care. Narrow networks also limit choice for patients with a smaller pool of providers and hospitals.

Quality and quantity

The year 2014 will be about cost control, says a recent report from consulting giant pricewaterhousecoopers (PwC) titled “Medical Cost Trend: Behind the Numbers 2014” despite one of the greatest healthcare insurance expansions in history. “For an industry that until recently had consistently seen double-digit growth, the ongoing slowdown poses immediate financial challenges. At the same time, the imperative to do more with less has paved the way for a true transformation of the health ecosystem, from fee-for-service medicine to consumer-centered care that rewards quality outcomes,” PwC says. Traditional fee-for-service is moving toward a payment structured leaning toward compensation based on outcomes. And many variations will likely surface. Models that will be further developed include:

bundled payments for services, (and in some cases bundled payments for multiple providers),

episode of care, (providers paid to treat a specific condition over a period of time),

Physician Quality Reporting System (incorporating quality metrics),

shared savings programs (physicians split savings with the insurer), and

Patient-Centered Medical Home

High-deductible health plans will also pose business challenges for most practices and will require a more aggressive collection policy at the time of visit. PwC estimates that employers offering high-deductible plans as their only option has grown 31% since 2012.

Opportunities abound

And while the predictions sound dire, there are plenty of opportunities for primary care to assert its leadership, showcase its status as a relative bargain among healthcare providers, and advance its mission to experiment with direct pay, ancillary services, and team up with employers and insurers to capitalize on innovative wellness programs to improve the health of your patient population and the practice’s bottom line. Primary care will need to reinvent its services to patients, reassess its use of technology to better monitor population health and engage patients in new ways.

Challenge #2: Government mandates2014: The year of the government mandate

When primary care physicians (PCPs) of the future look back on 2014, they may well recall it as the “year of the mandate.” That’s because PCPs will see their practices affected by four major government-sponsored requirements:

Of these, the requirement to use the ICD-10-CM coding system will probably have the greatest impact, for the simple reason that practices not using the new code set will no longer be reimbursed by third-party payers. The ICD-10-CM codes require a far greater level of specificity than the current ICD-9-CM code set, and thus require training for coders, billers, and providers, as well as extensive changes to—and testing of—billing software. A 2008 study estimated that conversion costs will range from $83,000 to $2.7 million, depending on the size of the practice.

Meaningful use: Attest next year or face penalties

The coming year will also be important for doctors taking part in the government’s Meaningful Use (MU) incentive program to adopt electronic health record (EHR) systems. Those who successfully attested to MU1 in 2011 or 2012 can choose any 90-day period in 2014 to meet their MU2 objectives and qualify for the next round of incentive payments. In addition, 2014 is the last year in which doctors who have not previously participated in MU can do so and avoid financial penalties beginning in 2015.

The biggest challenge many doctors will face in attesting to MU2 is meeting the requirements for electronically exchanging patients’ health information with other providers, especially those using a different EHR system. EHR vendors are working to include information exchange capabilities in their systems. Participating in a health information exchange network will also enable doctors to meet the interoperability requirements, although the networks are not available everywhere.

HIPAA’s more comprehensive rule for guarding patients’ protected health information (PHI)—and more stringent penalties for failing to do so—began in September, but 2014 will be the first full year in which medical practices feel their effect.

Among other things, HIPAA rules require a practice to conduct and document a risk analysis for their PHI, review its practices and procedures for when PHI is lost or stolen, having the ability to send health information to patients electronically, and update its notice of privacy and ensure its availability to patients. The HIPAA rule also sets and describes the four categories of penalties for rule violations and the dollar amounts for each.

PQRS: Reward next year, penalties in 2015

The final mandate requiring PCPs’ attention in 2014 is PQRS, the federal program that rewards physicians and practices for successfully reporting on 138 outcome quality measures. That’s because 2014 is the last year in which the financial rewards—equal to 0.5% of covered Medicare Part B Physician Fee Schedule (PFS) services—are available. Beginning in 2015, the incentive turns into a penalty equal to 1.5% of covered Part B PFS services. The penalty rises to 2% in 2016. To-date, physicians’ participation in PQRS has been fairly low. It remains to be seen whether the threat of a penalty will cause more doctors to report.

Challenge #3: Payer headaches and the fine print

Navigating a convoluted payment maze

The health insurance landscape is more uncertain now than it has ever been. Many physicians are feeling they are on uneven ground, with insurance companies having the upper hand when it comes to how and if they can properly treat the patients who choose to see them.

The Affordable Care Act has caused many insurance companies to make drastic changes—dropping physicians from panels, causing patients to scramble for new plans and new doctors, and making the whole process of finding quality healthcare even more confusing and tedious.

Medical Economics recently polled physicians on their concerns for 2014, and dealing with payers was one of the top issues cited. “Getting done what patients need will be very difficult if we have to call for everything including for medications,” one doctor told Medical Economics anonymously. “Paymentwise, MDs have no say. Take it or leave it. Like UnitedHealthcare thinks now patients are theirs and not doctors’.”

“Insurance companies dictate which doctor, which medicine, which test, how long in the hospital,” said another surveyed physician. “Insurance companies have planted themselves between the patient and doctors and on top of the money pile.”

Unitedhealthcare drops physicians

In a developing story, UnitedHealthcare cut physicians from its Medicare Advantage program, with plans to reduce its 350,000-nationwide physician panel by up to 52,500 in 2014.

Doctors in at least 10 states have already received letters from multiple payers telling them they are no longer part of certain networks, according to the American Medical Association. Aside from class-action lawsuits, restraining orders, and appealing, which could take months or years, there isn’t much a physician can do to fight back against being dropped. Experts believe that the uncertainty surrounding health insurance will continue to fall on physicians—and that patients will ultimately be the ones to suffer as a result. UnitedHealthcare is said to be the first of many payers who will start dropping Medicare Advantage physicians, and any other physicians who can’t adhere to strict metrics that don’t fully consider quality of care.

Prior authorizations consume time, money

In the office, prior authorizations continue to sap time and money from practices. With more time and staff dedicated to communicating with payers, prior authorization activities can cost a practice up to $3,430 per full-time physician, according to a 2013 study published by the Journal of the American Board of Family Medicine.

“This all wastes a lot of our time, and it’s not reimbursed,” says Jeffrey Kagan, MD, an internal medicine practitioner in Newington, Connecticut, and Medical Economics editorial adviser. “I feel that if an authorization has to be done the insurance company should allow a higher level of billing for the visit or a surcharge. I’m sure attorneys don’t bring motions before a judge for free.”

With more patients entering the healthcare system and more payers involved with more physicians, the pressure from insurance companies is not likely to yield in 2014 or in the near future.

Challenge #4: Time

Finding time for patients despite escalating administrative noise

Primary care physicians (PCPs) pursued medicine because they want to help patients. But every year, physicians complain they are spending less time with patients and more time dealing with the noise that surrounds the business of medicine.

In 2014, it may be deafening.

So, what is the noise? It’s all the requirements that pull physicians away from seeing patients and helping them become or remain healthy. It’s the government regulations and private payer requirements they must meet; it’s the day-to-day difficulty of trying to a run a business, not have enough time.

Next year may be a perfect storm that forces physicians to spend even less time with their patients. The rollout of the Affordable Care Act means business uncertainty, new requirements, and possibly floods of newly-insured patients crowding already busy patient panels. October 1 has been set as the date for the switchover to International Classification of Diseases, 10th Revision, Clinical Management (ICD-10-CM) coding language. Practices that don’t successfully make that switch will simply not get paid.

In addition, practices will either be playing catch-up to meet Meaningful Use 1 or embarking on the much more challenges stage 2 requirements.

Medical Economics provided physicians with an opportunity to make anonymous comments about the challenges facing primary care. Many were concerned that the onslaught of requirements are drowning out the joy of why they chose medicine in the first place.

“I love the patient interaction as much as ever but it is being slowly eroded by so many factors which are beyond our control,” a physician told Medical Economics. “I think both the patient and the physicians are fearful about the future of medicine.”

“We are still slowed down 2-plus years after switching to an EHR, and there seems to be a never-ending stream of updates and other expenses, not to mention the costs of the IT guys when something goes wrong,” Rebecca Preston, MD, a family physician at Preston Family Practice in Western Springs, Illinois, told Medical Economics in a recent poll. “I dread the thought of ICD-10, especially when a lot of it does not have anything to offer me as a primary care doctor.”

This is even more of a challenge when physicians see much of the technology they must purchase as a hindrance, not a benefit, to their practice.

“Many practice-based physicians will be challenged to find time and resources to fully understand all of these programs and associated operational implications, and implement new and updated supporting technologies while focusing on their primary role—patient care,” says Mickey McGlynn, Health Information and Management Systems Society EHR Association chair.

Though there are EHR holdouts—20% of primary care physicians still don’t have them, and 34% say they don’t plan on ever getting an EHR system, according to Medical Economics 2013 Continuing Survey—the reality is that technology upgrades could make or break your business in the next year.

“Our industry is in a period of rapid transformation. Physician practices are doing more and more to innovate and respond to our rapidly changing environment to meet the needs of their patients, but with fewer resources,” says Susan L. Turney, MD, MS, FACMPE, FACP, president and chief executive officer of the Medical Group Management Association.

In this installment of Why Medical Licensing in Puerto Rico Is So Difficult, we will cover some eligibility requirements, time-frames & expectations.

What you need to know:

Expiration: Applications usually expire after 1 year from the date it is received by the Board

This Board does not accept FCVS profiles.

Interview: Not required

The Board loses an average of 1 in 5 pieces of mail every week; expect to re-request documentation at some point during the process.

The Board will not answer phones or e-mail as a general rule of thumb.

The Board will consider hand-delivered applications first and foremost. If you have a friend or family member who can walk documents directly into the Medical Board in Rio Piedras, your chances of success are much higher.

The website www.salud.gov.pr is NOT active and nobody is currently monitoring the web correspondence. That website has not been updated in the last 24 months and none of the current board employees are allowed to login to the site at the present time. Information on the site cannot be trusted as accurate nor current.

The Board strongly prefers that all communication be in Spanish. If you are fluent in Spanish and you conduct all verbal and written communication in Spanish, you will be more likely to receive a response from the Board. Alternatives include using a translation application to convert all your correspondence to Spanish before sending to the analyst in Puerto Rico.

Eligibility Requirements:

USMLE Attempt Limit: None

USMLE Time Limit: Must complete USMLE steps I, II, & III within 7 years of passing the first step

PGY (AMG): 1 Year

PGY (IMG): 1 Year

SPEX/COMVEX: Not required

ECFMG not required

Background check required – very quick and affordable compared to other states (BCI is recommended)

Question Regarding References from Puerto Rico Licensed Physicians:

Q. If I’ve never worked or been licensed in Puerto Rico, how on Earth am I supposed to get a PR licensed physician to give me a reference?

A.If you work with a physician in your home state who holds a license in PR, that will satisfy the requirements. Please note that there are not a lot of actively licensed physicians who are licensed in Puerto Rico and meeting this requirement is not always an option. Just be advised that this can significantly delay your medical license.

In all, licensing in Puerto Rico presents different challenges that applicants will not find in other states, but with the expertise and knowledge of Physician Licensing Service, we can make the process as painless as possible.

About Physician Licensing Service

Now in our 16th year of business, Physician Licensing Service has been changing the face of healthcare licensure. We have developed a proven system to remove the barriers common to state medical licenses and get doctors practicing in record time. Our business model focuses on simplifying the process for all involved parties. This includes the state medical boards themselves, because PLS takes great care to keep abreast of their updates in this ever changing field, and work within those guidelines. For a doctor seeking a medical license, PLS will take on the entire process, including eligibility research, paperwork, verifications, and follow up.

If you’ve ever made event the most rudimentary inquiries into researching the requirements for a Physician License in Puerto Rico, then you’ve likely come up against an impenetrable wall. The Puerto Rico Medical Board won’t answer their phones of e-mails most of the time, and doesn’t even have a useable website containing pertinent information – so getting answers is nearly impossible.

We receive numerous calls each and every week from people seeking answers or solutions. The most common question is, “Why can’t I get in touch with them?”

The Puerto Rico licensing question is a difficult one to answer and there is currently no easy solution to be found. Perhaps the best way to understand the problem in Puerto Rico is to take a look at recent board history to understand how the current landscape came to be.

A federal grand jury indicted 88 doctors following an investigation into members of the US territory’s medical-licensing board, who allegedly altered low test scores to certify unqualified candidates.

The doctors paid board members bribes as much as $10,000, according to the indictment. Most of the suspects failed the licensing exam multiple times.

At least five states recognize Puerto Rican medical licenses — Arizona, Florida, New York, Texas, and Virginia — but none of the suspects were known to have practiced on the mainland, according to Puerto Rico’s medical licensing board.

The defendants face charges that include mail fraud and making false statements to Medicare. If convicted, most face five to 20 years in prison.

In all, 113 indictments were brought against nearly ninety suspects in 2008, including Puerto Rico board members and employees – the medical board has struggled to recover from the scandal. Since the Government sought cooperation from the FSMB in its investigation and owing to the island’s inherent mistrust of mainland politics, the Puerto Rico Medical Board has since limited all communication with those outside of the territory – including the FSMB, it’s overseeing entity.

Since 2008, turnover at the Puerto Rico Medical Board has been astronomically high, whether from fear or apathy, is hard to say – but each time Physician Licensing Service develops a solid, responsive contact at the medical board, that employee is gone with-in months. Maintaining a relationship with individual employees and building rapport remains a challenge to this day. Even our independent contacts on the ground in Puerto Rico have difficulty in getting timely answers at present.

Physician Licensing Service has discussed these issues directly with the Federation, which is keenly aware of the problems, and we are still actively seeking resolution with them – but the FSMB is currently hesitant to impose sanctions on the Puerto Rico Medical Board, fearing that the appearance of punitive action against the board will further exacerbate the existing problem.

Until an accord is reached, Physician Licensing Service will continue to strive for the very best possible solutions to applicants seeking licensure in Puerto Rico.

About Physician Licensing Service

Now in our 16th year of business, Physician Licensing Service has been changing the face of healthcare licensure. We have developed a proven system to remove the barriers common to state medical licenses and get doctors practicing in record time. Our business model focuses on simplifying the process for all involved parties. This includes the state medical boards themselves, because PLS takes great care to keep abreast of their updates in this ever changing field, and work within those guidelines. For a doctor seeking a medical license, PLS will take on the entire process, including eligibility research, paperwork, verifications, and follow up.

2013 was a record setting year for PLS. During the year we strategized and implemented a broad-scale restructure in an effort to improve leadership, increase efficiency, and make our innovative licensing processes even more effective. The result from this introspection is even better licensing services to both individual doctors and large corporate clients alike. Our licensing consultants are more proficient and better trained. In fact, one of our Consultants issued nearly 600 medical licenses in 2013. That’s more than most licensing companies produce in a year’s time.

Companywide we reduced the cost per issued license by 30%. We reduced the hours of work per issued license by 35% while increasing total licenses issued by more than 5%. Those are big shifts. About to celebrate our 17th anniversary, PLS has been in medical licensing more than twice as long as our nearest competitor. From telemedicine, to the Affordable Care Act, to an aging US population, the medical industry is experiencing a number of forces pulling it in a variety of directions. Medical licensing serves a vital purpose as an anchor through all of this change. It ensures that consumers of healthcare receive safe and effective care. Physician Licensing Service is working daily to make sure we are in the best possible position to serve an expanding section of the US economy and to take good care of the people we trust to care for our loved ones.

About Physician Licensing Service

Now in our 16th year of business, Physician Licensing Service has been changing the face of healthcare licensure. We have developed a proven system to remove the barriers common to state medical licenses and get doctors practicing in record time. Our business model focuses on simplifying the process for all involved parties. This includes the state medical boards themselves, because PLS takes great care to keep abreast of their updates in this ever changing field, and work within those guidelines. For a doctor seeking a medical license, PLS will take on the entire process, including eligibility research, paperwork, verifications, and follow up.